Conceptual model to inform Legionella-amoebae control, including the roles of extracellular vesicles in engineered water system infections.

Extracellular vesicles (EVs or exosomes) are well described for bacterial pathogens associated with our gastrointestinal system, and more recently as a novel mechanism for environmental persistence, dissemination and infection for human enteric viruses. However, the roles played by EVs in the ancient arms race that continues between amoebae and one of their prey, Legionella pneumophila, is poorly understood. At best we know of intracellular vesicles of amoebae containing a mix of bacterial prey species, which also provides an enhanced niche for bacteriophage infection/spread. Free-living amoeba-associated pathogens have recently been recognized to have enhanced resistance to disinfection and environmental stressors, adding to previously understood (but for relatively few species of) bacteria sequestered within amoebal cysts. However, the focus of the current work is to review the likely impacts of large numbers of respiratory-sized EVs containing numerous L. pneumophila cells studied in pure and biofilm systems with mixed prey species. These encapsulated pathogens are orders of magnitude more resistant to disinfection than free cells, and our engineered systems with residual disinfectants could promote evolution of resistance (including AMR), enhanced virulence and EV release. All these are key features for evolution within a dead-end human pathogen post lung infection. Traditional single-hit pathogen infection models used to estimate the probability of infection/disease and critical environmental concentrations via quantitative microbial risk assessments may also need to change. In short, recognizing that EV-packaged cells are highly virulent units for transmission of legionellae, which may also modulate/avoid human host immune responses. Key data gaps are raised and a previous conceptual model expanded upon to clarify where biofilm EVs could play a role promoting risk as well as inform a more wholistic management program to proactively control legionellosis.

Microbial contamination of drinking water and disease outcomes in developing regions.

Drinking water is a major source of microbial pathogens in developing regions, although poor sanitation and food sources are integral to enteric pathogen exposure. Gastrointestinal disease outcomes are also more severe, due to under-nutrition and lack of intervention strategies in these regions. Poor water quality, sanitation and hygiene account for some 1.7 million deaths a year world-wide (3.1% of all deaths and 3.7% of all DALY's), mainly through infectious diarrhoea. Nine out of 10 such deaths are in children and virtually all of the deaths are in developing countries. Major enteric pathogens in these children include: rotavirus, Campylobacter jejuni, enterotoxigenic Escherichia coli, Shigella spp. and Vibrio cholerae O1, and possibly enteropathogenic E. coli, Aeromonas spp. V. cholerae O139, enterotoxigenic Bacteroides fragilis, Clostridium difficile and Cryptosporidium parvum. All except the latter are easily control by chlorination of water, but recontamination of treated water is a huge problem. Emerging environmental pathogens, such as Helicobacter pylori and Burkholderia pseudomallei, may well be of significance in some regions. In adults, much less is understood of various sequellae such as myocarditis, diabetes, reactive arthritis and cancers some months-years after initial infections. So in addition to the traditional pathogens (helminths, Entamoeba histolytica, Giardia lamblia hepatitis A and E) various enteroviruses, C. jejuni and H. pylori are emerging issues in adults.

Risk analysis of drinking water microbial contamination versus disinfection by-products (DBPs).

Managing the provision of safe drinking water has a renewed focus in light of the new World Health Organization (WHO) water safety plans. Risk analysis is a necessary component to assist in selecting priority hazards and identifying hazardous scenarios, be they qualitative to quantitative assessments. For any approach, acute diarrhoeal pathogens are often the higher risk issue for municipal water supplies, no matter how health burden is assessed. Furthermore, potential sequellae (myocarditis, diabetes, reactive arthritis and cancers) only further increase the potential health burden of pathogens; despite the enormous uncertainties in determining pathogen exposures and chemical dose-responses within respective microbial and chemical analyses. These interpretations are currently being improved by Bayesian and bootstrapping approaches to estimate parameters for stochastic assessments. A case example, covering the health benefits of ozonation for Cryptosporidium inactivation versus potential cancers from bromate exposures, illustrated the higher risks from a pathogen than one of the most likely disinfection by-products (DBPs). Such analyses help justify the industries long-held view of the benefits of multiple barriers to hazards and that microbial contamination of water supplies pose a clear public health risk when treatment is inadequate. Therefore, efforts to reduce potential health risks from DBP must not compromise pathogen control, despite socio-political issues.